Ectopic Pregnancy

Topic Overview

What is an ectopic pregnancy?

In a normal
pregnancy, a fertilized egg travels through a
fallopian tube to the
uterus. The egg attaches in the uterus and starts to
grow. But in an ectopic pregnancy, the fertilized egg attaches (or implants)
someplace other than the uterus, most often in the fallopian tube. (This is why
it is sometimes called a tubal pregnancy.) In rare cases, the egg implants in
an ovary, the cervix, or the belly.

There is no way to save an ectopic pregnancy. It
cannot turn into a normal pregnancy. If the egg keeps growing in the fallopian
tube, it can damage or burst the tube and cause heavy bleeding that could be
deadly. If you have an ectopic pregnancy, you will need quick treatment to end
it before it causes dangerous problems.

What causes an ectopic pregnancy?

An ectopic
pregnancy is often caused by damage to the fallopian tubes. A fertilized egg
may have trouble passing through a damaged tube, causing the egg to implant and
grow in the tube.

Things that make you more likely to have
fallopian tube damage and an ectopic pregnancy include:

Smoking. The more you smoke, the higher your
risk of an ectopic pregnancy.

What are the symptoms?

In the first few weeks, an
ectopic pregnancy usually causes the same symptoms as a normal pregnancy, such
as a missed menstrual period, fatigue, nausea, and sore breasts.

The key signs of an ectopic pregnancy are:

Pelvic or belly pain. It may be sharp on one
side at first and then spread through your belly. It may be worse when you move
or strain.

Vaginal bleeding.

If you think you are pregnant and you have these
symptoms, see your doctor right away.

How is an ectopic pregnancy diagnosed?

A urine
test can show if you are pregnant. To find out if you have an ectopic
pregnancy, your doctor will likely do:

A pelvic exam to check the size of your
uterus and feel for growths or tenderness in your belly.

A blood
test that checks the level of the pregnancy hormone (hCG). This test is
repeated 2 days later. During early pregnancy, the level of this hormone
doubles every 2 days. Low levels suggest a problem, such as ectopic pregnancy.

An
ultrasound. This test can show pictures of what is
inside your belly. With ultrasound, a doctor can usually see a pregnancy in the
uterus 6 weeks after your last menstrual period.

How is it treated?

The most common treatments are
medicine and surgery. In most cases, a doctor will treat an ectopic pregnancy
right away to prevent harm to the woman.

Medicine can be used if
the pregnancy is found early, before the tube is damaged. In most cases, one or
more shots of a medicine called methotrexate will end the pregnancy. Taking the
shot lets you avoid surgery, but it can cause side effects. You will need to
see your doctor for follow-up blood tests to make sure the shot worked.

For a pregnancy that has gone beyond the first few weeks, surgery is
safer and more likely to work than medicine. If possible, the surgery will be
laparoscopy (say "lap-uh-ROSS-kuh-pee"). This type of
surgery is done through one or more small cuts (incisions) in your belly. If
you need emergency surgery, you may have a larger incision.

What can you expect after an ectopic pregnancy?

Losing a pregnancy is always hard, no matter how early it happened. Take
time to grieve your loss, and get the support you need to make it through this
time.

You could be at risk for
depression after an ectopic pregnancy. If you have
symptoms of depression that last for more than a couple of weeks, be sure to
tell your doctor so you can get the help you need.

It is common to
worry about your fertility after an ectopic pregnancy. Having an ectopic
pregnancy does not mean that you can't have a normal pregnancy in the future.
But it does mean that:

You may have trouble getting pregnant.

You are more likely to have another ectopic pregnancy.

If you get pregnant again, be sure your doctor knows that
you had an ectopic pregnancy before. Regular testing in the first weeks of
pregnancy can find a problem early or let you know that the pregnancy is
normal.

Cause

Fallopian tube damage is a common cause
of
ectopic pregnancy. A fertilized egg can become caught
in the damaged area of a tube and begin to grow there. Some ectopic pregnancies
occur without any known cause.

Common causes of
fallopian tube damage that may lead to an ectopic pregnancy include:

Smoking. Women who smoke or who used to smoke
have higher rates of ectopic pregnancy. Smoking is thought to damage the fallopian
tubes' ability to move the fertilized egg toward the uterus.

Shoulder pain caused by
bleeding into the abdomen under the
diaphragm. The bleeding irritates the diaphragm and is
experienced as shoulder pain.

Symptoms of
miscarriage often are similar to symptoms experienced
in early ectopic pregnancy. For more information, see the topic
Miscarriage.

What Happens

Normally, at the beginning of a
pregnancy, the fertilized egg travels from the
fallopian tube to the
uterus, where it implants and grows. But in a small number of diagnosed pregnancies, the fertilized egg attaches to an area outside of the
uterus, which results in an
ectopic pregnancy (also known as a tubal pregnancy or
an extrauterine pregnancy).

An
ectopic pregnancy cannot support the life of a fetus for very long. But an
ectopic pregnancy can grow large enough to rupture the area it occupies, cause
heavy bleeding, and endanger the mother. A woman with signs or symptoms of an
ectopic pregnancy requires immediate medical
care.

The egg attaches and grows in an ovary, the
cervix, or the abdominal cavity (outside of the
reproductive system).

One or more eggs
grow in the uterus, and one or more grow in a fallopian tube, the cervix, or
the abdominal cavity. This is called a
heterotopic pregnancy.

Complications of ectopic pregnancy

Ectopic
pregnancy can damage the fallopian tube, which can make it difficult to become
pregnant in the future.

Ectopic pregnancies are usually detected
early enough to prevent deadly complications such as severe bleeding. A
ruptured ectopic pregnancy requires emergency surgery
to prevent heavy bleeding into the abdomen. The affected tube is partially or
fully removed. For more information, see Surgery.

What Increases Your Risk

Things that can increase
your risk of having an
ectopic pregnancy include:

A
previous ectopic pregnancy.

Past or
present cigarette smoking. The more you smoke, the higher the risk. Experts suspect that
smoking affects fallopian tube function.

Medical treatments and procedures that can increase your risk of having an ectopic pregnancy include:

Previous fallopian tube surgery to treat
infertility or to reverse a
tubal ligation.

A tubal ligation failure.
In rare cases when pregnancy happens after a sterilization surgery, there is a
higher-than-usual risk that the pregnancy is ectopic.

A
progestin-only birth control failure, such as progestin-only pills, or a pregnancy that
happens with an
intrauterine device (IUD) in place.

Treatment with
assisted reproductive technology (ART), such as
in vitro fertilization (IVF). This may result from the flushing of the fertilized egg into
a damaged fallopian tube after it is transferred to the uterus.

Infection after any kind of surgery done on the uterus or fallopian tubes. This
can lead to scar tissue.

Ectopic pregnancy has been linked to the use of medicine
used to make the ovary release multiple eggs (superovulation). Experts do not yet know whether this
is because many women using it already have fallopian tube damage or because of
the medicine itself.

If you become pregnant and are at high risk for ectopic pregnancy, you will
be closely watched. Doctors do not always agree about which risk factors are
serious enough to watch closely. But research suggests that risk is serious
enough if you have had a tubal surgery or an ectopic pregnancy before, had DES
exposure before birth, have known fallopian tube problems, or have a pregnancy
with an intrauterine device (IUD) in place.

When To Call a Doctor

If you are pregnant, be alert to
the symptoms that may mean you have an
ectopic pregnancy, especially if you are at risk.
If you have symptoms of an ectopic pregnancy or you are being treated for an ectopic pregnancy, avoid
strenuous activity until your symptoms have been evaluated by a doctor.

Call 911 or other emergency services immediately if:

You passed out (lost consciousness).

You have severe vaginal bleeding.

You have sudden, severe pain in your belly or pelvis.

Call your doctor now or seek immediate medical care if:

You are dizzy or lightheaded, or you feel like you may faint.

You have vaginal bleeding.

You have new cramps or new pain in your belly or pelvis.

Who to see

The following health professionals
can evaluate you for an ectopic pregnancy:

Exams and Tests

Most
ectopic pregnancies can be detected using a pelvic
exam, ultrasound, and blood tests. If you have symptoms of a possible ectopic
pregnancy, you will have:

A pelvic exam, which can detect tenderness in
the
uterus or
fallopian tubes, less enlargement of the uterus than
expected for a pregnancy, or a mass in the pelvic area.

A
pelvic ultrasound (transvaginal or abdominal), which
uses sound waves to produce a picture of the organs and structures in the lower
abdomen. A transvaginal ultrasound is the most dependable way to show where a
pregnancy is. A pregnancy in the uterus is visible 6 weeks after the last
menstrual period. An ectopic pregnancy is likely if there are no signs of an
embryo or fetus in the uterus but hCG levels are
elevated or rising.

Two or more blood tests of pregnancy hormone
(human chorionic gonadotropin, or hCG) levels, taken 48
hours apart. During the early weeks of a normal pregnancy, hCG levels double
every 2 days. Low or slowly increasing levels of hCG in the blood suggest an
early abnormal pregnancy, such as an ectopic pregnancy or a
miscarriage. If hCG levels are abnormally low, further
testing is done to find the cause.

Sometimes a surgical procedure using
laparoscopy is used to look for an ectopic pregnancy.
An ectopic pregnancy after 5 weeks can usually be diagnosed and treated with a
laparoscope. But laparoscopy is not often used to diagnose a very early ectopic
pregnancy, because ultrasound and blood pregnancy tests are very
accurate.

Follow-up testing after treatment

During the week
after treatment for an ectopic pregnancy, your hCG (human chorionic
gonadotropin) blood levels are tested several times. Your doctor will look for
a drop in hCG levels, which is a sign that the pregnancy is ending (hCG levels
sometimes rise during the first few days of treatment, then drop). In some
cases, hCG testing continues for weeks to months until hCG levels drop to a low
level.

What to think about

If you become pregnant and are at high risk for an ectopic pregnancy, you will be
closely watched. Doctors do not always agree about which risk factors are
serious enough to watch closely. But research suggests that risk is serious
enough if you have had a tubal surgery or an ectopic pregnancy before, had
DES exposure before birth, have known fallopian tube
problems, or have a pregnancy with an
intrauterine device (IUD) in place.

A urine pregnancy test—including a
home pregnancy test—can accurately diagnose a
pregnancy but cannot detect whether it is an ectopic pregnancy. If a urine
pregnancy test confirms pregnancy and an ectopic pregnancy is suspected,
further blood testing or ultrasound is needed to diagnose an ectopic
pregnancy.

Treatment Overview

In most cases, an
ectopic pregnancy is treated right away to avoid
rupture and severe blood loss. The decision about which treatment to use
depends on how early the pregnancy is detected and your overall condition. For
an early ectopic pregnancy that is not causing bleeding, you may have a choice
between using medicine or surgery to end the pregnancy.

Medicine

Using
methotrexate to end an ectopic pregnancy spares you
from an incision and
general anesthesia. But it does cause side effects and
can take several weeks of hormone blood-level testing to make sure that
treatment has worked. Methotrexate is most likely to work:

Surgery

If you have an ectopic
pregnancy that is causing severe symptoms, bleeding, or high hCG levels,
surgery is usually needed. This is because medicine is not likely to work and a rupture
becomes more likely as time passes. When possible,
laparoscopic surgery that uses a small incision is
done. For a
ruptured ectopic pregnancy, emergency surgery is
needed.

Expectant management

For an early
ectopic pregnancy that appears to be naturally miscarrying (aborting) on its
own, you may not need treatment. Your doctor will regularly test your blood to
make sure that your pregnancy hormone (hCG, or human chorionic gonadotropin)
levels are dropping. This is called
expectant management.

Ectopic pregnancies
can be resistant to treatment.

If hCG levels do not drop or bleeding does not
stop after taking methotrexate, your next step may be surgery.

What to think about

Surgery versus medicine

Methotrexate is usually the first treatment
choice for ending an early ectopic pregnancy. Regular follow-up blood tests are
needed for days to weeks after the medicine is injected.

There are
different types of surgery for a tubal ectopic pregnancy. As long
as you have one healthy fallopian tube, salpingostomy (small tubal slit) and
salpingectomy (part of a tube removed) have about the same effect on your
future fertility. But if your other tube is damaged, your doctor may try to do
a salpingostomy. This may improve your chances of getting pregnant in the
future.

Although surgery is a faster treatment, it can cause scar
tissue that could cause future pregnancy problems. Tubal surgery may damage the
fallopian tube, depending on where and how big the embryo is and the type of
surgery needed.

Surgery may be your only treatment option if you have internal bleeding.

Prevention

You cannot prevent ectopic pregnancy, but you can
prevent serious complications with early diagnosis and treatment. If you have
one or more risk factors for ectopic pregnancy, you and your doctor can closely
monitor your first weeks of a pregnancy.

If you smoke, quit to lower your
risk of
ectopic pregnancy. Women who smoke or who used to
smoke have higher rates of ectopic pregnancy.

Home Treatment

If you are at risk for having an ectopic pregnancy and you think you may be pregnant, use a
home pregnancy test. If it is positive, be sure to
have a confirmation test done by a doctor, especially if you are concerned
about having an
ectopic pregnancy.

If you are receiving methotrexate treatment to end an ectopic pregnancy, you
may experience side effects from the medicine. See these
tips for managing methotrexate treatment to
minimize these side effects.

If you experience an ectopic pregnancy loss, no matter how early in a pregnancy, expect
that you and your partner will need time to grieve. It is also possible to
develop
depression from the hormonal changes after a pregnancy
loss.
If you have
symptoms of depression that last for more than a
couple of weeks, be sure to call your doctor or a
psychologist,
clinical social worker, or
licensed mental health counselor.

You can contact a support group, read about the experiences of other women,
and talk to friends, a counselor, or a member of the clergy. These things may help you and
your family deal with a pregnancy loss.

Concerns about future pregnancy

If you have had an
ectopic pregnancy, you may worry about your
chances of having a healthy or ectopic pregnancy in the future. Your risk factors and any fallopian tube damage you may have
will impact your future risk and your ability to become pregnant. Your doctor
can answer your questions based on your risk factors.

Medications

Medicine can only be used for early
ectopic pregnancies that have not ruptured. Depending
on where the ectopic growth is and what type of surgery would otherwise be
used, medicine may be less likely than surgical treatment to cause
fallopian tube damage.

Medicine is most
likely to work when an early ectopic pregnancy is not causing bleeding
and:

Methotrexate versus surgery

If your ectopic
pregnancy is not too far advanced and has not ruptured, methotrexate may be a
treatment option for you. Successful methotrexate treatment of an early ectopic
pregnancy avoids the risks of surgery, may be less likely to damage the
fallopian tube than surgery, and is more likely to preserve your
fertility.

If you are not concerned with preserving fertility,
surgery for an ectopic pregnancy is faster than methotrexate treatment and will
likely cause less bleeding.

Surgery

At any stage of development, surgical removal
of an ectopic growth and/or the
fallopian tube section where it has implanted is the
fastest treatment for
ectopic pregnancy. Surgery may be your only treatment
option if you have internal
bleeding. When possible, surgery is done through a small incision using
laparoscopy. This type of surgery usually has a short
recovery period.

Surgery choices

An ectopic pregnancy can be removed from a fallopian tube
by using salpingostomy or salpingectomy.

Salpingostomy. The ectopic growth is
removed through a small, lengthwise cut in the fallopian tube (linear
salpingostomy). The cut is left to close by itself or is stitched closed.

Salpingectomy. A fallopian tube segment
is removed. The remaining healthy fallopian tube may be reconnected.
Salpingectomy is needed when the fallopian tube is being stretched by the
pregnancy and may rupture or when it has already ruptured or is very damaged.

Both salpingostomy and salpingectomy can be done either
through a small incision using
laparoscopy or through a larger open abdominal
incision (laparotomy). Laparoscopy takes less time than laparotomy. And the hospital stay is shorter. But for an
abdominal ectopic pregnancy or an emergency tubal ectopic removal, a laparotomy
is usually required.

What to think about

When an ectopic pregnancy is
located in an unruptured
fallopian tube, every attempt is made to remove the
pregnancy without removing or damaging the tube.

As long
as you have one healthy fallopian tube, salpingostomy (small tubal slit) and
salpingectomy (part of a tube removed) have about the same effect on your
future fertility. But if your other tube is damaged, your doctor may try to do
a salpingostomy. This may improve your chances of getting pregnant in the
future.

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